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  Discussion on Enthesopathy of the Hip
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New Member:
thechtel

Posted on Monday, Oct 11, 2010 - 8:21 pm:

Dr. Oglesby-

I received some very difficult news today regarding my 8 yr old Friesian who has been competing as a dressage horse. I'd like to share a bit of background in the hopes that you might have some suggestions for me. Forgive me for being long winded but this horse is truly my dream horse and I am heart broken. I've had him since he was 3 and hearing the news I heard today felt like letting go of a dream. Not only had he had great success in competition, but he and I have a very special relationship.

Approximately 5 months ago my horse was diagnosed with proximal suspensory desmitis in his rear left leg. He was diagnosed through a lameness exam, nerve blocking and an ultrasound. We did 3 rounds of shock wave therapy and he had almost 4 months of stall rest with limited hand walking. He also had several chiropractic treatments in his left hip area which seemed to bring him quite a bit of relief. When we performed his final ultrasound we saw dramatic improvement in the tissue, the ligament had reduced in size, the fibers looked much more aligned and with clearer edges. He looked completely sound upon his exam and was cleared for 5 minutes of walking under saddle.

The first time I got on him I immediately knew that he had a pain issue from the way he was acting and I dismounted after about 1 minute and I could immediately see that he was lame again. His lameness showed up not only in his hip but he would consistently drag his left hind hoof on the ground with his toe hitting the ground approximately mid-arc in his stride. We put him back on stall rest and performed two subsequent lameness exams in which the left leg was systematically blocked up through his stifle. We performed his blocks two different times with 10 days in between as the first time we were very surprised to see that he showed no improvement when the block associated with his suspensory was given. We continued as far up his leg and into his stifle with blocks, none of those blocks changed his lameness. When his initial block was performed 5 months earlier to help diagnosis his lameness we saw a dramatic improvement when his suspensory was blocked. Ultimately it was determined the he would go to a well known veterinary university where several of the doctors had performed many surgical treatments of the suspensory and are well respected authorities in this area.

He had a scintigram as we suspected he might have something in addition to the suspensory issue. He had been clicking and popping in his left hip and stifle area since his original diagnosis although it did clear up briefly at the end of his stall rest. It returned immediately after our brief couple of days under saddle and although everyone told me that wasn't a sign of an abnormality it was very difficult for me to accept given that he had never clicked or popped before and now he was clicking in that area sometimes every other stride.

Back to the scintigram-upon completion of the exam I was told that he had an enthesopathy of the hip which involved his glutues medius. The vet said that this was quite rare in his experience and that he had only seen three cases and that none of those horses returned to soundness. He had operated on two, but neither was sound after 6 months. The other was put down. He said he couldn't tell for sure whether it was an avulsion facture, break down of the bone itself or calcium deposits in the muscle or potentially some combination of those. He was very grim about the likelihood that my horse would ever be rideable again and certainly didn't think he could return to his former level of work. He did say that he would call some of his international colleagues and see if they had any success with other treatment. He offered the experimental option of shock wave therapy. He said that he wasn't aware of this modality ever being used in that area because the injury is so deep thus his comments about it being unproven. I will speak with him again tomorrow so hopefully he will have some better news from overseas but I'm trying to be realistic. The irony in all of this is that his suspensory ligament looked like it had healed just fine.

Some of the questions that I'd like your help with are your opinion about any other treatment options that you have heard were successful in treating this type of injury. The questions I dread asking are if this can't be corrected and accepting that he won't be rideable, does he have to spend the rest of his life in a small paddock? I can't imagine that would be any kind of a life but if I put him out to pasture is he at high risk of injurying himself further? He doesn't appear to be in a tremendous amount of pain but he is extremely stoic and never having seen a horse with this type of injury I don't have anything to compare to. And if a horse is put down for this type of issue is it because it is the humane thing to do or would that be for other reasons?

Although I held it together today when I spoke to him, I'm not sure that I'm going to be able to do that for these questions. Any insight you can provide would be much appreciated. Thank you.
Member:
36541

Posted on Tuesday, Oct 12, 2010 - 8:57 am:

Tami, I'm sorry to welcome you to HA under such difficult circumstances. Many of us here have been through similar emotions when this diagnostic/prognostic dilemma becomes central to the horse-owning experience. Having had some of the same horses for 20+ years, I am still amazed when they beat the odds with respect to healing. Have hope, it sounds like a long road but your boy may yet amaze you... Stacy
Moderator:
DrO

Posted on Tuesday, Oct 12, 2010 - 6:49 pm:

Welcome Tami,
The problem is, as your vet has stated, we don't know the cause of the enthesopathy. Though it could be a primary tendon to the gluteal's tendinous attachment to the bone, often such lesions result from trauma to the surrounding tissues.

Have lesions been identified or are we operating off a "hot spot" on a scintogram? Diagnostic ultrasound (both transdermal and transrectal) and radiography (a difficult procedure in the hip of horses requiring general anesthesia) could be considered. After that exploratory surgery is a possibility I would guess but I have not seen such a case myself so this is conjecture. I agree with him that standard shock wave therapy units are not designed for tissues this deep.

As to your questions on paddock vs pasture retirement issues and possible euthanasia, these things all depend on your goals, resources, the severity of the lameness and gait dysfunction. We don't have the information needed to decide and really should be made by you in council with those professionals who can examine the horse. If you find you disagree with the council you can always seek another's opinion. Many very lame horses however are quite happy living out their lives on pasture.
DrO
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